Printable Iowa 470 3361 Form in PDF

Detailed Guide for Writing Iowa 470 3361

The process of filling out the Iowa 470 3361 form is essential for referring children in DHS custody who have severe disabilities to the SSI ADVOCACY PROJECT for potential eligibility for Supplemental Security Income benefits. The completed form ensures that MAXIMUS can appropriately assess and support the application for benefits on behalf of the child. Careful attention to detail and accuracy in providing the required information will streamline the process and help in identifying eligible children more efficiently.

1. Begin by entering the Child's Name at the top of the form. Include the first, middle, and last names to ensure clear identification.
2. Fill in the Date of Birth of the child, using the format MM/DD/YYYY to avoid any confusion.
3. Input the child's Social Security Number carefully to ensure accuracy.
4. Under "Foster Care Parents/Facility," provide the name of the foster care parents or the facility where the child is currently placed. Follow this by entering the Telephone number, including the area code.
5. Fill in the Street, City, State, and Zip Code associated with the child's current location.
6. Document the Date of Placement to provide context on how long the child has been in the current setting.
7. Answer whether there is a court order placing the child in DHS or JCS custody by checking "Yes" or "No."
8. Indicate whether the child has a diagnosed mental/physical impairment by checking the appropriate box. If "No" is selected for either of the previous two questions, stop here as the referral cannot proceed.
9. Review the list of indicators that might qualify a child for the SSI program. Check all that apply to the child's situation.
10. If applicable, answer whether the child is receiving any benefits based on a deceased, disabled, or retired parent’s account by selecting "Yes" or "No."
11. Finally, fill in the information regarding the individual making the referral under "Referred By." Include County, Telephone, and the Date of referral.
12. Once all the necessary information is filled in, send the referral to MAXIMUS via fax or email as provided at the bottom of the form. Additionally, it's important to report any placement changes to MAXIMUS directly to ensure up-to-date information is on file.

After submitting the form, MAXIMUS will review the referral and initiate the application process for SSI benefits if the child appears to be eligible. This step is crucial in supporting children with severe disabilities in DHS custody, providing them with potential access to benefits that can aid in their care and wellbeing. Ensure all information is accurate and complete before submission to facilitate this important process.

What is the Iowa 470 3361 form used for?

The Iowa 470 3361 form is utilized by the Iowa Department of Human Services as a referral document for the SSI Advocacy Project. It is specifically designed to identify children in DHS custody with severe disabilities who may be eligible for Supplemental Security Income (SSI) benefits. Once a child is determined to be potentially eligible, MAXIMUS is authorized to file an application for SSI benefits on behalf of the child.

Who can initiate a referral using the Iowa 470 3361 form?

Referrals can be initiated by individuals or professionals who have identified a child within the Iowa Department of Human Services custody presenting severe disabilities. This typically involves caseworkers or social workers within DHS, but can also include healthcare professionals, educators, or other individuals involved in the child's care and welfare.

What are the eligibility indicators mentioned in the form?

Eligibility indicators for SSI benefits as mentioned in the form include: psychiatric hospital services due to a diagnosed mental impairment (excluding substance abuse), stay in a residential facility for mental impairments, receipt of special education for severe learning problems, intensive outpatient counseling or therapy, moderate to severe mental retardation (IQ 70 or less), severe developmental delays, intensive medical services for physical illness, or being an infant with a very low birth weight (1200 grams or less).

What should be done if a child does not meet the eligibility criteria listed on the form?

If a child does not meet the specified eligibility criteria—does not have a diagnosed mental/physical impairment or there isn't a court order placing the child in DHS or JCS custody—the referral process should not be proceeded with. It suggests that the child may not be eligible for SSI benefits under the guidelines provided by the Iowa Department of Human Services and MAXIMUS.

How can someone contact MAXIMUS regarding the referral process?

Individuals wishing to contact MAXIMUS for inquiries about the referral process or to initiate a referral can do so by calling 1-800-778-1406. Additionally, referrals can be sent via fax to 515-284-8854 or via email to iowassi@maximus.com.

Is there a section on the form for documenting changes in the child's placement?

Yes, the form emphasizes the importance of reporting any changes in the child's placement to MAXIMUS. Such changes are crucial for maintaining current information that could affect the child's eligibility or need for SSI benefits, highlighting the necessity for up-to-date communication.

Can the form be submitted electronically?

Yes, the form allows for electronic submission via fax or email to MAXIMUS. This flexibility ensures that the referral process can be initiated promptly, aiding in quicker identification and support for eligible children.

What information is required on the form regarding the child?

Information required includes the child's name, date of birth, Social Security Number, foster care parents/facility contact details, street address, city, state, zip code, date of placement, court order status, diagnosed mental/physical impairments, and any current benefits the child may be receiving based on a deceased, disabled, or retired parent’s account.

Who should be contacted for updates or inquiries after the referral is submitted?

After submitting the referral form, MAXIMUS serves as the primary contact for updates or any inquiries regarding the child's case. This ensures a streamlined communication process between the referring individual or entity and the organization handling the SSI application process.

Filling out official documents requires precision, and the Iowa 470 3361 form, used for identifying children eligible for Supplemental Security Income (SSI) due to severe disabilities, is no exception. Despite its critical role, mistakes can occur during the process. Here are some of the common errors to watch for:

1. Incomplete Child’s Information: Not filling out the child's full name, date of birth, or Social Security Number can delay the process. This basic information is crucial for identifying the child within the system.
2. Skipping Contact Details: Forgetting to provide complete contact information for the foster care parents or facility, including phone number and address, hinders necessary follow-ups and correspondence.
3. Incorrect Placement Dates: Misreporting the date of placement can lead to confusion regarding the child’s eligibility timeline. Accuracy in this section is essential for processing the application smoothly.
4. Neglecting Court Order Details: Failing to accurately indicate whether there is a court order placing the child in DHS or JCS custody can result in a stalled referral. This confirmation is pivotal for the child's eligibility.
5. Omitting Disability Information: Not specifying whether the child has a diagnosed mental/physical impairment or checking the relevant boxes indicating the nature of the child’s disabilities overlooks essential eligibility criteria.
6. Skipping Other Benefits Query: Not answering whether the child is receiving any benefits based on a deceased, disabled, or retired parent’s account leaves out a vital consideration for determining the child's SSI eligibility.
7. Forgetting to Indicate Referral Source: Not including the referral source information, such as who referred the child, the county, and contact number, can obscure the referral's origin and potentially delay verification processes.
8. Failure to Report Placement Changes to MAXIMUS: Not adhering to the instruction to report any changes in the child’s placement to MAXIMUS can affect the child’s eligibility and the continuation of benefits.

Avoiding these errors requires diligence and attention to detail. Providing accurate and complete information not only streamlines the process but also ensures that eligible children receive the benefits they need without unnecessary delay. Professionals filling out this form play a crucial role in supporting the well-being of children with severe disabilities in DHS custody.

When preparing to engage with the Iowa Department of Human Services, specifically in relation to the SSI Advocacy Project Referral (form 470 3361), it's important to understand the scope of additional documents and forms that can support or are required alongside your main submission. These documents enhance your application, provide critical information, and comply with regulatory requirements. Below is a compiled list of key documents often used in conjunction with the Iowa 470 3361 form.

• Medical Records: Comprehensive medical records that document the child’s diagnosed mental or physical impairments are crucial. These records provide evidence of the condition's existence and its impact on the child’s daily life.
• Court Order for Custody: If the child is in DHS or JCS custody, a copy of the court order that placed the child in this arrangement must be included. This document verifies the legal status of the child’s placement.
• Special Education Plan (IEP): For children receiving special education services, the Individualized Education Program (IEP) outlines the educational accommodations and support services the child requires, serving as evidence of the child's needs.
• Social Security Earnings Statement: For children receiving benefits from a deceased, disabled, or retired parent’s account, the most recent Social Security earnings statement should be attached to show the current benefits status.
• Proof of Income and Assets: Documentation related to the income and assets of the child or their family may be required to assess eligibility for SSI benefits.
• Proof of Placement: This document confirms the child’s current living arrangement, whether in foster care or a residential facility, and supports the information provided on the referral form.
• Proof of Age: A birth certificate or other government-issued identification verifies the child’s date of birth, which is necessary for SSI eligibility determination.
• Treatment Plans: For children receiving intensive medical services, outpatient counseling, or therapy, detailed treatment plans can prove the child’s ongoing needs and eligibility for benefits.
• Guardianship Documents: If applicable, legal documentation that establishes guardianship or custody agreements outside of DHS or JCS custody may be necessary.
• Discharge Papers from Residential or Psychiatric Facilities: For children who were recently discharged from such facilities, these documents can provide background on the child's condition and the reasons for discharge, offering insight into their current needs.

Each of these documents plays a vital role in constructing a comprehensive advocacy package for children in need of SSI benefits. By thoughtfully compiling and including these documents with the Iowa 470 3361 form, stakeholders can ensure a more effective and streamlined process, ultimately assisting in the provision of crucial support to children with severe disabilities.

The Social Security Administration's Form SSA-8001-F5, "Application for Supplemental Security Income (SSI)", is quite similar to the Iowa 470 3361 form as both serve the purpose of initiating a process to determine eligibility for SSI benefits. The SSA-8001-F5 is a comprehensive application that collects detailed information about an individual's financial, medical, and living situation to assess their eligibility for SSSI, paralleling how the Iowa form identifies children in DHS custody with severe disabilities for SSI benefits. Both documents necessitate detailed personal information and health status to facilitate the benefits application process.

Form SSA-3368, "Disability Report - Adult," shares similarities with the Iowa 470 3361 form, primarily in gathering medical and disability-related information. This form is used by individuals or their representatives to provide the Social Security Administration with the medical evidence and history needed to evaluate disability claims. Like the Iowa 470 3361 form, it collects detailed information about the applicant's medical condition, treatments, and any impact on daily living, aiding in the determination of eligibility for disability benefits.

The "Child’s Disability Report" form, also known by its form number SSA-3820, is closely related to the Iowa 470 3361 form. It is specifically designed to collect information about a child’s medical condition and how it affects their ability to function, mirroring the Iowa form’s objective to identify children with severe disabilities. Both forms play a crucial role in the process of determining a child's eligibility for SSI benefits by laying out the medical evidence and the severity of the child’s condition.

Form SSA-827, "Authorization to Disclose Information to the Social Security Administration," complements the Iowa 470 3361 form by authorizing the release of medical and other information to the SSA. Applicants often submit this form alongside their SSI or disability application forms to allow the SSA to obtain the necessary records to make an eligibility determination. This parallels the Iowa form’s function of identifying eligible children and facilitating their application process by presumably requiring similar consent to gather and share medical or disability information with relevant parties.

The "Application for Child’s Insurance Benefits" (Form SSA-4-BK) is used to apply for Social Security benefits for children of retired, disabled, or deceased workers, which requires information about the child's condition and dependency status, somewhat akin to portions of the Iowa 470 3361 form. While the SSA-4-BK is more focused on the child's relationship and dependency on the insured worker, both forms seek information that helps determine benefits eligibility based on medical conditions or other qualifying criteria.

Finally, the "Adult Disability and Work History Report" (Form SSA-3369-BK) is designed for adults but parallels the Iowa 470 3361 form in its purpose to collect detailed information on the applicant's medical condition and work history. Though targeted at adults, the essence of gathering comprehensive disability-related information to assess SSI or SSDI eligibility is a shared objective with the Iowa document. Both serve as vital steps in documenting the severity of conditions and the potential for benefits eligibility.

When completing the Iowa 470 3361 form for the SSI Advocacy Project Referral, accurate and thorough information is essential to ensure a smooth process. Below are several important dos and don'ts to consider:

• Do ensure the child's name, date of birth, and social security number are correctly entered. Accuracy in these details is critical for identity verification and eligibility checks.
• Do verify whether there is a court order placing the child in DHS or JCS custody, as this information is crucial for proceeding with the referral.
• Do check all applicable indicators that suggest the child may qualify for the SSI program. Providing complete information here helps MAXIMUS in assessing eligibility more efficiently.
• Do accurately provide contact information for the foster care parents/facility, including a current telephone number and address. This ensures that any necessary follow-up can be conducted without delay.
• Do indicate if the child is receiving any benefits based on a deceased, disabled, or retired parent’s account. This information is necessary for determining potential eligibility for additional benefits.
• Don't proceed with the referral if the answers to the questions about court custody or diagnosed impairments are "no". This form is specifically for children under DHS or JCS custody with diagnosed disabilities.
• Don't forget to report any placement changes to MAXIMUS. It is important to keep the information up to date to ensure the continuation and accuracy of the assistance provided.

Adhering to these guidelines will help in the efficient and accurate completion of the Iowa 470 3361 form, facilitating a smoother process for all parties involved.

Many individuals have misunderstandings regarding the Iowa 470 3361 form and its usage within the Supplemental Security Income (SSI) advocacy project. It is essential to clarify these misconceptions to ensure accurate and efficient use of the form.

• Misconception #1: The form is applicable for any child with disabilities.

  The form specifically targets children in the custody of the Department of Human Services (DHS) or Judicial Court Services (JCS) with severe disabilities potentially eligible for SSI benefits.

• Misconception #2: MAXIMUS is a part of the Iowa Department of Human Services.

  While MAXIMUS assists in identifying eligible children for SSI benefits, it operates as a separate entity contracted by the DHS, not as a part of DHS itself.

• Misconception #3: Any child receiving special education qualifies for referral.

  Referral criteria specify that a child must have severe learning problems addressed through special education, among other indicators, to qualify for SSI benefits.

• Misconception #4: A diagnosed mental or physical impairment automatically qualifies a child.

  A diagnosis is a starting point; however, the form requires additional indicators, such as receiving psychiatric hospital services or intensive therapy, to proceed with the SSI benefits application.

• Misconception #5: The form is used for applying to SSI benefits directly.

  Actually, the form initiates the referral process for MAXIMUS to file an application on behalf of the eligible child; it does not directly apply for SSI benefits.

• Misconception #6: Parents or foster care facilities can't initiate the referral.

  While the form seems focused on children in the custody of DHS or JCS, parents or foster care facilities can contact MAXIMUS for inquiries or potential referrals, indicating a broader scope of initiator roles.

• Misconception #7: The criteria listed for SSI eligibility via the form are exhaustive.

  The form lists common indicators of eligibility, but each child's case can present unique attributes that may also be considered for SSI eligibility.

Understanding these clarifications ensures that individuals are better informed about the Iowa 470 3361 form's purpose and use, promoting accurate referrals and aiding in the identification of children in DHS or JCS custody who may be eligible for SSI benefits.

When dealing with the Iowa Department of Human Services SSI Advocacy Project Referral, specifically form 470 3361, there are several essential points of consideration to ensure accurate and effective completion and submission of this form. Understanding these points is vital for professionals handling cases involving children in DHS custody who have severe disabilities and may be eligible for Supplemental Security Income (SSI) benefits. Here are the key takeaways:

• Eligibility Identification: The form is designed for the express purpose of identifying children under the custody of the Department of Human Services (DHS) or Judicial Council Services (JCS) who may be eligible for SSI benefits due to severe disabilities. MAXIMUS, a contracted entity, takes on the responsibility of filing the application on behalf of eligible children.
• Contact Information: For questions or clarifications about the referral process, MAXIMUS has provided a direct line (1-800-778-1406). It is crucial for those filling out the form or seeking to make a referral to have this contact information at hand to ensure any inquiries can be promptly addressed.
• Referral Criteria: The form specifies a series of indicators to help determine a child's potential eligibility for SSI benefits. These indicators range from psychiatric hospital services due to mental impairments (excluding substance abuse) to receiving intensive medical services for physical illnesses. A child being born at a very low birth weight (1200 grams or less) is also a noted criterion. It is important to carefully review and check all that apply to the child in question.
• Requirement for Additional Information: Should there be a change in the child’s placement, the form mandates reporting these changes back to MAXIMUS. This requirement underlines the necessity for ongoing communication between the referring party and MAXIMUS to ensure the continuity and accuracy of the benefits application process.

Overall, the Iowa 470 3361 form is a structured tool intended to facilitate the process of securing SSI benefits for children in need. Its careful completion and the prompt update of any pertinent information are key to maximizing the support provided to eligible children with severe disabilities under DHS or JCS custody.